Basic Information
| Provider Information | |||||||||
| NPI: | 1700801073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK GIBSON | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 219672 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641219672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164074200 | ||||||||
| FaxNumber: | 8167816973 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167813515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2011007284 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 35789048 | 01 | MO | BCBS | OTHER | 309393 | 05 | SC | MEDICAID | 5909852 | 01 | NC | MEDICAID NC | OTHER |